Functional results after mesorectal excision for rectal cancer: comparative study among surgical approaches.

BACKGROUND: We analyzed the evolution of genitourinary dysfunctions in patients undergoing surgical treatment for rectal cancer, and compared open surgery, laparoscopy, robotic and TaTME. METHODS: Functional outcomes were evaluate using standardized questionnaires, compiled at the start of treatment, after the end of Radiotherapy, at 1 and 6 months after surgery. RESULTS: In 72 patients 37.5% had low, 27.8% middle, and 34.7% high rectal cancers. Open technique was performed in 25% of cases, while 29.2% underwent laparoscopy, 20.8% TaTME and 25% robotic. We noted a deterioration in urogenital function: surgical technique can influence the result both in urinary and male sexual function but not ejaculation. Robotics and laparoscopy bring better outcomes than open surgery and TaTME. Female sexuality worsening seems not influenced by the technique. In general age, stage, complications, and anastomotic leakage appear to be predictive factors for functional dysfunctions. As reported in literature rectal cancer treatment leads to urogenital worsening: this seems to be progressive in male sexuality only, while female one and urinary function show a slight improvement in the first months, although a full recovery possibility is discussed. Is also reported how robotic and laparoscopy have a lower functional impact. TaTME has gained consensus thank to the excellent oncological and function outcomes, but in our study leads to worse results. CONCLUSIONS: Mini-invasive techniques guarantee the same oncological result than more invasive ones, but with better functional outcomes and tolerability; robotic surgery seems to be slight superior to laparoscopy, but with longer operative time.

PTH after Thyroidectomy as a Predictor of Post-Operative Hypocalcemia.

Post-thyroidectomy hypocalcemia is a frequent complication with significant morbidity, and has been shown to increase hospital stay and readmission rates. The evaluation of serum parathyroid hormone (PTH) levels after thyroidectomy represents a reliable method to predict post-thyroidectomy hypocalcemia, but it remains infrequently used. This retrospective study investigates serum PTH values 3 h after thyroidectomy as a predictor of hypocalcemia. In this study, we enrolled 141 patients aged between 27 and 71 years eligible for total thyroidectomy who presented with multinodular goiter, suspicious nodule on cytological examination, Graves' disease, or toxic multinodular goiter. Three hours after total thyroidectomy, 53 patients (37.6%) showed a reduction in serum PTH. Of these patients 75.5% developed hypocalcemia by 24 h after surgery and 100% were hypocalcemic after 48 h (p < 0.001). There was no significant difference attributable to the different thyroid diseases, nor to the age of the patients. PTH at 3 h after total thyroidectomy accurately predicts post-operative hypocalcemia. The early detection of patients at risk of developing post-operative hypocalcemia allows for prompt supplementation of calcium and Vitamin D in order to prevent symptoms and allows for a safe and timely discharge.

Recto-Urinary Fistula (RUF) treated by Transanal Endoscopic Microsurgery (TEM) Review of the literature and surgical technique.

AIM: Recto-Urinary Fistula (RUF) is a rare complication of pelvic surgery. Different approaches are reported in literature but a gold standard treatment has not yet been achieved. Transanal Endoscopic Microsurgery (TEM) is a miniinvasive approach with well known advantages as magnification, 3D view and lighting of the operative field. Aim of the present review is to report the current evidence in literature about technique and results of RUF treatment by TEM and to suggest some key points for its correct management. MATERIALS OF STUDY: After a medline in Pubmed and Scopus databases, seven papers were eligible for the present study. Data were reviewed on the basis of the cases reported, patient's characteristics, surgical techniques and results. RESULTS: Eighteen cases have been reported in the literature from 1996 to 2005. The healing success rate was 77.8%. Fecal and urinary diversion were performed before TEM-assisted procedure in the 83% and 94% of cases, respectively. Recurrence was observed in four patients (22%). DISCUSSION: A gold standard treatment of RUF should ensure the complete removal of scar tissue around the fistula, in order to perform a tension free suture on healthy margins with adequate vascularization. Preoperative stoma improves the healing of the fistula, reducing local inflammation and infections. CONCLUSIONS: There is not common view of this topic in literature and clarify which could be the best treatment is a key condition due to high failure rate of the surgical proposed techniques. Recurrences treatment has a lower cure rate if compared to primary lesions, nevertheless more studies are required to confirm this data. KEY WORDS: Recto-Urinary Fistula (RUF), Transanal Endoscopic Microsurgery (TEM), Transanal approach.

Spleen preserving laparoscopic distal pancreatectomy for treatment of pancreatic lesions.

AIM: Aim of this study is to evaluate the feasibility and safety of the laparoscopic approach in the treatment of distal pancreas tumors, from prospectively collected data. MATERIAL OF STUDY: From January 2003 to July 2013, 20 patients were treated by laparoscopic approach for distal pancreatic lesions. Nine patients underwent laparoscopic pancreatic tumorectomy (LPT) (Group A) for insulinoma (mean lesion diameter 1.2 cm, range, 0.5-2) and 11 patients underwent spleen preserving laparoscopic distal pancreatectomy (SP-LDP) (Group B) for ductal adenocarcinoma (pT1N0R0) (1), cystic mucinous neoplasm (5), serous cystadenoma (4) and lymphoepithelial cysts (1). RESULTS: Mean operative time was 94.3 minutes (range 80-110) for Group A and 164 minutes (range 90-240) for Group B. Intraoperative bleeding occurred in 4 cases (20%) and was easily controlled by laparoscopy. Conversion to open surgery was not required in any case. Morbidity was observed in 2 patients (18%) in Group A: pancreatic fistula (1) and peritoneal fluid collection (1); and a peritoneal fluid collection occurred in one patients (11%) in Group B. Mean hospital stay was 6.8 days (range 3-11) in Group A and 6.5 days (range 3-10) in Group B. Mortality was nil. At a mean follow-up of 82 months (range 15-141) local recurrence and distant metastases were not observed. DISCUSSION: LDP is a valid treatment showing the same rate of complication to open surgery but allowing the advantages of a minimally invasive procedure. CONCLUSIONS: SP-LDP is feasible and safe for benign and malignant pancreatic lesions.

Treatment of recto-vesical fistula by transanal endoscopic microsurgery approach.

INTRODUCTION: Rectovesical Fistula (RVF) is a rare major surgery complication. Despite different techniques have been proposed as yet there is still no standard treatment. Transanal Endoscopic Microsurgery provides a magnified three-dimensional vision and it is less invasive than the traditional surgical procedure used in RVF treatment. MATERIALS AND METHODS: A 62 years-old man, who developed a rectovesical fistula after laparoscopic radical prostatectomy, underwent TEM-assisted RVF repair by full-thickness excision and both bladder and rectal wall suture. The patients had a temporary ileostomy RESULTS: The patient could ambulate on day one, was fed on day three and was discharged on day 10 with the indwelling bladder catheter left in place. The ileostomy was taken down and the catheter removed three months later when colonoscopy and cystoscopy showed no rvf recurrence. DISCUSSION AND CONCLUSIONS: From 2004, only ten cases of TEM-assisted treatment of RVF are reported with three recurrences and good results even in patients who had already undergone previous surgical attempts. TEM is safe and effective. It provides a tension free suture line on healthy tissue with adequate hemostasis and it may be a good alternative in the treatment of rectovesical fistula. KEY WORDS: Endoscopic Surgery, Microsurgery, Recto-vesical Fistula, Transanal Endoscopic.